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British Journal of Oral and Maxillofacial Surgery 48 (2010) 310311

Technical note

A new anatomical landmark to simplify temporomandibular

joint arthrocentesis
Alper Alkan, Osman A. Etz
Erciyes University Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Kayseri, Turkey
Accepted 29 June 2009
Available online 28 July 2009

Keywords: Temporomandibular joint; Arthrocentesis

Arthrocentesis of the temporomandibular joint (TMJ) was

first described by Nitzan et al.1 and is an accepted treatment
for various disorders of the TMJ. Their technique includes
insertion of two needles along the canthal-tragal line, the first
of which is placed into the upper joint compartment of the
TMJ, and the second anterior to the first to allow effective
lavage of the joint (Fig. 1). However, in some cases it is difficult to insert the second needle, which means that lavage fails,
the operation takes longer, the patient is uncomfortable, and
there may be increased postoperative morbidity and possible
damage to the facial nerve.2 For this reason single needle
arthrocentesis has been proposed, in which inflow and outflow go through the same cannula.2 The joint is lavaged with a
single needle used for injection and ejection resulting 40 ml
of irrigation. However, with a single needle the amount of
fluid may be inadequate and the pressure too low.
Previously, we have used a single cannula with two ports
and two lumens that allow irrigation and lavage of the joint
with the same device and permit sufficient irrigation under the
desired pressure.3 Rehman and Hall4 used a similar device
called a Shepard cannula that holds two needles together.
Nevertheless the device that keeps two needles together
seems to be relatively thick, which has the potential to damage the nerve. Repetitive use of the device may cause the tips
of the needles to blunt, and increase the risk of infection.
We propose a new technique, by which the patients are
asked to open and close the mouth several times so that the

Corresponding author. Address: Erciyes Universitesi Dis Hekimligi

Fakultesi Cerrahi Bolumu, 38039 Melikgazi, Kayseri, Turkey.
Fax: +90 352 438 06 57.
E-mail address: (O.A. Etz).

Fig. 1. Placement of the first (1) and second needles (2) in the conventional
approach for arthrocentesis of the temporomandibular joint. In the technique
that we have described, the second needle (3) is 3 mm posterior to the first
needle (1), which was inserted 10 mm anterior and 2 mm inferior along the
canthal-tragal line.

condylar head of the mandible can be palpated. They are

then instructed to keep the mouth open and a 21 gauge needle with a 10 ml syringe is inserted 10 mm anterior and 2 mm
inferior along the canthal-tragal line and oriented 30 posterior and inferior to the sagittal plane until bony contact has
been made at the medial wall of the glenoid fossa. The second
needle is inserted 7 mm anterior and 2 mm inferior along the
canthal-tragal line and should be adjusted parallel and almost
3 mm posterior to the first needle until bony contact is made
(Figs. 1 and 2).
We used this landmark when we were faced with failed
outflow through an anteriorly placed second needle, and have
thoroughly irrigated numerous joints with complete success
when the second needle is inserted posterior to the first one

0266-4356/$ see front matter 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.


A. Alkan, O.A. Etz / British Journal of Oral and Maxillofacial Surgery 48 (2010) 310311

Fig. 2. Effective washout of the joint with the described technique.


(Fig. 2). Laskin mentioned that insertion of the second needle anterior to the first one is usually difficult, and he has
inserted the anterior needle in the posterior recess of the
upper joint compartment by placing it 34 mm anterior to
the first one.5 However, if the second needle is anterior
to the first one it is inserted into a narrower region of the
upper joint compartment (Fig. 3), and this may cause damage to the disc and unexpected failure of outflow. Outflow
is easier to achieve when the second needle is inserted posterior to the first one in the wider part of the upper joint
The use of this landmark as the default technique may be
reasonable, as repeated insertions of a needle are uncomfortable both for physicians and patients and adversely affect the
success of the treatment.


Fig. 3. The second needle anterior to the first one would be in the narrower
part of the posterior upper joint compartment (black arrow) and closer to
the articular disk (D). (Reprinted from: Nanci A. Ten Cates oral histology:
development, structure and function. Chicago: Mosby, 2003; reproduced by
permission of the publisher.)

1. Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening. J Oral
Maxillofac Surg 1991;49:116370.
2. Guarda-Nardini L, Manfredini D, Ferronato G. Arthrocentesis of the
temporomandibular joint: a proposal for a single-needle technique.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:
3. Alkan A, Bas B. The use of double-needle canula method for
temporomandibular joint arthrocentesis: clinical report. Eur J Dent
4. Rehman KU, Hall T. Single needle arthrocentesis. Br J Oral Maxillofac
Surg 2009;47:4034.
5. Laskin DM. Needle placement for arthrocentesis. J Oral Maxillofac Surg